Inspection on 17/04/07 for The Cedars

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Cedars 15/12/05

The Cedars 16/05/05

The Cedars 03/11/04

The Cedars 22/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Cedars Church Side Methley Leeds West Yorkshire LS26 9BH Lead Inspector Sue Dunn Unannounced Inspection 17th April 2007 10:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address Church Side Methley Leeds West Yorkshire LS26 9BH 01977 512 993 01977 604088 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Cedars Partnership Kathleen B Morgan Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39) of places The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: The Cedars, located in the village of Methley, near to Castleford, is classed as being in the Leeds area. The home can accommodate up to thirty-nine older people, including up to 39 people diagnosed with Dementia. The home does not provide nursing care. Local healthcare teams give healthcare support to the home. Accommodation is provided in two buildings, the main house and the ‘Cottage’. The main house has rooms for twenty-six residents. An enclosed courtyard provides a safe area for residents to walk and sit in the fresh air. Bedrooms are situated over four floors and some of these are in a modern extension. Access to the upper floors is provided by a passenger lift and a stair lift in addition to the stairs. There are eighteen single and four shared bedrooms, two of these with en-suite facilities. The Cottage has nine single rooms, one having en-suite facilities. One of the two double rooms also has en-suite facilities. Access to all rooms is via the staircase. The home is situated in large attractive gardens with parking. A large enclosed courtyard provides secure outdoor space for people with dementia to use safely and independently. The weekly fees for the home are from £383.63 to £412.00. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcomes for service users. The inspection report is divided into separate sections with judgements made for each outcome group. The judgements reflect how well the service delivers outcomes to the people using the service. The categories are “excellent”, “good”, “adequate” and “poor”. More detailed information about these changes is available on our website – www.csci.org.uk. The manager completed a pre-inspection questionnaire and this information with information supplied since the last inspection was used as part of the inspection process. Questionnaire leaflets were taken to the home to be given to service users and relatives asking them to comment on the service. One inspector carried out the inspection visit arriving at 10:50 am without prior arrangement and leaving at 5 pm. During the visit, service users, staff visitors and the manager were spoken with, the care records of two service users were case tracked, staff records and other documentation was examined, there was a tour of the building, the food was sampled and care practices were observed. What the service does well: Service users, visitors and new staff commented on the warm and welcoming atmosphere created by the manager and staff team. There is a stable staff team, some having worked in the home for many years. An introductory care plan when people first enter the home ensures that they are supported during the early days after admission, introduced to other like minded service users and shown how to find their way around the building. Service users and relatives felt the care was good and any concerns were taken seriously and dealt with. Staff were observed to have a good rapport with service users and were relaxed and unhurried when performing care duties. An activity organiser is employed and a record is kept of the activity each person joins in with and the outcome. This is good practice as it allows activities to be person centred. The activity organiser had a good relationship with service users and was seen to adapt her approach to different people. The home gives people the opportunity to attend events in the local community and arranges an annual trip to a place chosen by the service users. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 6 The manager has built good links with a local clergywoman and weekly outings take place to the church for tea, cakes and spiritual support. As the polling station is nearby staff are able to use wheelchairs to take people to register their votes. Both buildings provide communal and a secure outdoor space to allow service users to walk about without restriction. The catering staff produced good home cooked food, adapting the preparation to accommodate the needs of people on special diets. The laundry, though small, was orderly and spotlessly clean with systems in place to reduce risks of cross infection. Service users clothing was seen to be well cared for. Staff are to be commended for their commitment to NVQ training, with 75 of staff having achieved the award. There is an annual training programme which covers all areas of training staff need to meet the needs of the service users. The manager’s many years of experience coupled with training and a common sense approach inspire confidence that the home will be managed in the best interests of service users. It was clear that there was a good working relationship between staff and senior management, some of whom visited the home on the day of the inspection. What has improved since the last inspection? What they could do better: There should be evidence to show that service users and /or their families are involved in developing a care plan which is centred on the individuality of the person and their preferences. This should be done as soon as possible after admission and include some background information which distinguishes one person from another. This is important if staff are to understand the needs of people who are unable to speak for themselves. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 7 All care plans must include enough detail to guide staff practices. There was insufficient detail in some of the care plans seen, which could lead to care being inconsistent or overlooked. Staff were seen to try to adapt their care approach but had a difficult task due to the mixture of service users, some with dementia and some mentally alert but with physical disabilities. This should be taken into consideration during the future development of the two parts of the building. Some minor adjustments could be made to the mealtime arrangements to improve the experience for service users and staff. Only one hazard was noted which related to a hairdryer wire trailing across a corridor and posing a potential trip hazard. The staff said they would reorganise the area to reduce the risk. The recruitment and selection procedures should be more robust in order to ensure residents are protected and to provide evidence that prospective employees are not discriminated against. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5, (6 is not applicable) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home’s assessment process is used to ensure peoples’ needs can be met. Prospective service users are able to visit the home to see if it is a place in which they would like to live and a copy of the terms and conditions of occupancy make clear what they can expect. EVIDENCE: Contracts had been prepared for the two most recent service users. A copy letter in the file showed the contract had been sent to family via social worker to be signed. A copy of the terms and conditions of occupancy accompany the document. This states that there is an initial trial stay of one calendar month. The number of the room to be occupied was written on the top of the contract. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 10 A pre admission assessment of needs for one person was well completed by a social worker and gave a good background history leading up to admission. Another file only had the home’s assessment, which had been done a couple of days before admission as the person was not known to other services. The manager, who carried out the assessment, had written a brief statement to show where the assessment had been carried out and to say the home would be able to meet the person’s needs. A relative said her mother had made the decision that the home would suit her needs following a visit. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health and personal care was based on individual needs and the people spoken with felt the care was good. However, this was not fully evidenced in all the care plans, staff relying more on verbal information to direct care, which could lead to care being inconsistent or overlooked. EVIDENCE: Care plans were all held in one loose leaf working file which is sectioned, each section with a photograph of the person, the care plans, risk assessments and daily records. A separate file for each person contains factual information and pre admission assessments. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 12 Two files for people who had been in the home for some time showed contact with GP’s and other professionals had been recorded. Care files for two recently admitted users of the service were used to track their admission and care since admission. One started well with a brief background history and an initial care plan which had enough detail to guide staff on what to do to help her settle into the home. For example, show her round the home, introduce her to people, sit her next to someone she could talk to, put an alarm on the bedroom door to alert staff if she was out of her room at night. This is good practice, however, it was the only care plan for the person, who had been in the home for nearly two months. The manager said that more detailed care plans were normally done after the 6 week review but in this case the review had not taken place and the care plan had been overlooked. A care worker of several years could not explain why there was nothing more in the care plan indicating that staff were not using the care plans as a working document to guide care but relying on daily verbal handover information. The care plans seen in the cottage were rather general in content using words such as, ‘support with personal needs’, ‘encourage to join activities’, ‘likes reading’. These could have been improved with more detail about the person’s preferences and more focus on the different levels of support for people with dementia to maintain their abilities and quality of life. An example of a typed care plan for a person in the main house was better developed giving more detailed information about how care was to be given. This approach (if written in a larger print as service users should be able to read their own care plans) gave much better guidance about each person’s personal preferences allowing care to be more ‘person centred’. Two relatives spoken with seemed unaware of the care planning process. They felt they were kept informed but had not attended any reviews of care plans other than the 6 weeks review involving the social worker. There should be evidence in the care files to show that relatives are given the opportunity to be involved in the plans of care, particularly for those service users who are unable to make their wishes known. Three visitors were spoken with. All felt the care was good and relatives had settled. All said staff were friendly and welcoming. One person said “I have visited frequently over couple of years and never seen anything that I have thought ‘that’s not right’.” There was some concern about the difficult job staff had in trying to care for such widely diverse needs. For example, some people were physically disabled and mentally alert and others were mobile but unable to converse because of The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 13 dementia. Staff were seen however to try to link up people who were able to converse with each other. People with dementia were said on occasions to be verbally abusive towards other people who use the service leading to some people preferring to stay in their rooms. Accidents were well recorded, giving details of the action taken. A senior care worker explained that staff giving medication had in house and distanced learning training on handling medication. The home uses a pre dispensed medication system and also individually prescribed liquid medications. Medication was in date and medication records were up to date. Each service user had a photograph and a description of their medication and its purpose so that staff could explain what they were giving and why. There were secure systems for controlled medications but none in use at the time of the visit. Blood sugar levels were checked for people with diabetes, and recorded. Staff were observed to have a good rapport with service users and relaxed and unhurried when performing care duties. Toilets were spacious, allowing staff to provide assistance without compromising privacy and dignity. There was screening (in one case a mobile screen) in the shared bedrooms. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service enjoy opportunities for social and recreational activities inside and outside the home. The well-balanced and nutritional home cooked meals are adapted to suit individual needs and preferences. Some minor practical adjustments could be made to improve mealtimes for people with dementia. EVIDENCE: The home employs an activity organiser who was working in different parts of the two buildings during the day. A group activity was underway during the morning, followed by a craft activity and later a group of users were encouraged to play dominoes. They clearly enjoyed this and continued playing after the activity organiser had left. A record is kept of the activity each person joins in with and the outcome. This is good practice as it allows activities to be person centred. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 15 The activity programme for a 3 month period showed special events. Day to day activities included knitting, drawing, board games, dancing and singing, trips around village. An annual trip is arranged by democratic means each person invited to make suggestions, which are then voted on. The manager has built good links with a local clergywoman and weekly outings take place to the church for tea, cakes and spiritual support. One person was taken out by visitors during the day and others were walking in and out or sitting in the secure enclosed courtyard. People were said to be able to use their own rooms when visitors came but in reality this would be difficult due to the layout of the home over 4 floors. There are plans to refurbish parts of the building, which should improve this. The meal was sampled and the quality of food and cooking found to be of a high standard with food hot when it reached the table. Provision is made for soft diets and diabetic options. All the people spoken with said the food was good. Some minor adjustments could be made to the mealtime arrangements to improve the experience for service users and staff. Staff were kneeling to assist people to eat due to a shortage of chairs. Folding chairs, which could be stored between meals would allow staff to sit in comfort. Tables were nicely laid but it is recommended that patterned table linen and mats be avoided and tables set using plain contrasting colours to reduce the distractions from the food for people with dementia. Staff should ensure that plate guards are used effectively and take account of whether the people using them are left or right handed. Protective clothing was supplied and paper napkins placed on tables. There was little conversation in the dining room during the course of the meal but staff showed an understanding of individual preferences. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has an effective and open attitude to complaints. People who use the service and their relatives felt they were able to raise any concerns without fear of repercussions. Service users are supported to take part in the political process. EVIDENCE: There had been no complaints since the last inspection visit. Relatives who have visited the home regularly over several years felt that any matters of concern brought to the attention of the manager were dealt with speedily and effectively. The last inspection report identified staff had a good understanding of adult protection and the staff group has remained stable with only three new staff appointed since that time. Protection is extended to staff with the manager issuing a clear warning to visitors that verbal abuse of staff will not be tolerated. All service users had received their polling cards. As the polling station is nearby staff are able to use wheelchairs to take people to register their votes. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 17 The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a safe, well-maintained and comfortable environment for the people that live there. The manager and registered providers continue to look at ways in which the environment can be improved to offer more space and privacy for service users. EVIDENCE: Both buildings provide communal and a secure outdoor space to allow service users to walk about without restriction. Information sent by the manager listed all the improvements made since the last inspection. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 19 Areas throughout the two buildings were clean and fresh smelling. Improvements listed by the manager in the pre inspection questionnaire were apparent throughout the home i.e.; Bathrooms and toilets had been upgraded and redecorated and en-suites redecorated. There was an ongoing programme of furniture and floor covering replacement and redecoration throughout both houses. There was a good selection of seating throughout the home suited to the comfort of people of all shapes and sizes. Outdoor security lights had been replaced and new garden furniture supplied. Bed linen and towels had been replaced and new washer/drier had been purchased. The laundry though small was orderly and spotlessly clean with systems in place to reduce risks of cross infection. Only one hazard was noted which related to a hairdryer wire trailing across a corridor and posing a potential trip hazard. The staff said they would reorganise the area to reduce the risk. Moving and handling equipment, hospital type beds and bed rails with padded bumpers were provided in some bedrooms as required. Where necessary for the protection of people who may wander at night, alarms had been fitted to bedroom doors to alert staff. Washing facilities included ordinary and special baths and showers. It has been recognised that bedrooms in some parts of the houses fall below current standards on space. The organisation has submitted a planning application for building work to will improve space and facilities in the home. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home ensures staff have training to be able to meet the needs of residents. The recruitment and selection procedures are not sufficiently robust to ensure residents are protected and to show evidence that prospective employees are not discriminated against. EVIDENCE: An annual training chart gave an overview of staff training. Each had their own file containing training certificates and other employment information. The projected training plan for the coming year included, first aid, fire awareness, Moving and Handling, Health and Safety, infection control, dementia, abuse, non clinical handling, challenging behaviour, continence, palliative care and medication. The manager plans to introduce in house training on ‘getting back to basics’ to increase staff awareness and understanding of what it is like to live with different disabilities. It was pleasing to note that a member of staff who had completed the dementia distanced learning course was starting to put some of her training The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 21 into practice and trying to understand why people might be displaying certain behaviours. The recruitment and selection documentation for a recent employee was examined. This included an interview checklist by the interviewer. In the interests of equal opportunities this process could be improved by having more than one person on an interview panel and by making more detailed notes to show how the decision to appoint (or not) had been reached. The file only contained one of two written references. Criminal Record Bureau checks for other staff showed that the practice was for staff to commence employment on the basis of a Protection of Vulnerable Adult check before CRB checks were returned to speed up the process. The manager was concerned that she might lose suitable staff if the period between interview and start was too long and said people were employed on a 6-week trial period, during which time they were supervised. However, two written references and a CRB check must be received before people start work. The person spoken with said she was working through her induction book. Examination of this showed a detailed record of what had been covered in the training and when. She said staff had been extremely welcoming and supportive, making the home a good place to work. The home has a stable staff and resident population with very little turnover. The manager described the staff and residents as being like ‘one big family’. The home is to be commended for its commitment to NVQ training, with 75 of staff having achieved the award. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 ,37, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed with an eye to ongoing development to improve the facilities and services for the people who live there. The health and safety of service users and staff is protected. EVIDENCE: The manager provided detailed information in the pre inspection questionnaire which indicated the home is well managed with attention to detail. The manager’s many years of experience coupled with training and a common The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 23 sense approach inspire confidence that the home will be managed in the best interests of service users. Regular meetings are held with the senior management team, some of whom visited the home on the day of the visit. It was clear that there was a good working relationship between staff and management. The manager works ‘hands on,’ therefore has a good knowledge of people who live in the home and can observe staff practices. A new deputy has been appointed which will give the manager more time to do some in house training on basic care practices and attention to detail. Staff supervision and appraisals will be shared between the two. The atmosphere in the home continues to be warm with lots of good humour. Records showed that there was a Fire drill and talk in Feb 07 Records showed that the environmental health officer visited the home in September 06 and recommendations had been implemented. Electrical equipment was checked in January 07 A 5 yearly NICIEC certificate for the electrical wiring was issued in 2004 The home’s Quality Assurance system was reviewed in Nov 06 Emergency/crisis procedure reviewed in Dec 06. A hazard with a trailing wire was noted as stated in the section on the environment. All parts of the home that might increase risks for those people with dementia were secure. Clear income and outgoing records were kept of personal allowances held on behalf of service users. Money was held in individual wallets, which is good practice. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 2 3 3 4 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 x 3 3 3 2 The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must include enough detail to guide staff and be developed with service users or their relatives as soon as possible after admission. Recruitment and selection procedures must be robust enough to protect service users and provide evidence that prospective employees are not discriminated against There must be safe arrangements for hairdressing to reduce trip hazards caused by trailing wires. Timescale for action 30/06/07 2 OP29 19 30/04/07 3 OP38 23 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations Some minor adjustments could be made to the mealtime arrangements to improve the experience for service users and staff. DS0000001621.V335277.R02.S.doc Version 5.2 Page 26 The Cedars 2. OP32 At the request of staff, management should arrange more regular staff meetings. The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars DS0000001621.V335277.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!